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In this series, we meet our new PhD fellows to find out what they will be researching and what they hope to achieve.

Lukasz Cybulski started his PhD in September 2017. He has a background in research and mental health work with an interest in the synthesis of public health policy, the use of research findings in the ‘real-world’ and ways of increasing research transparency and reproducibility. The opportunity to combine these interests is what drew him to the projects at the Greater Manchester Patient Safety Translational Research Centre.

His PhD will focus on self-harm and suicide in children, adolescents and young adults. The epidemiology (the study of how diseases affect the health and illness of populations) of self-harm and suicide has not been extensively studied among registered primary care patients. The majority of people diagnosed with a mental health disorder, including conditions such as depression, anxiety disorders and eating disorders, are rarely referred to, or treated by, specialist mental health services.

Lukasz will investigate this topic using a nationally representative group of primary care patients, linking with routinely collected clinical datasets and national mortality records. This will provide a unique platform for investigating people diagnosed with ‘mild to moderate’ mental health problems, their clinical management across healthcare sectors, and their subsequent risks of nonfatal and fatal suicidality and other causes of premature death. Epidemiological studies of this nature allow for the identification of populations at particular risk, and aid the development of clinical guidelines that maximise patient safety.

Health economics is a field of study concerned with the efficient use of resources within the health and social care sector. Efficiency is measured as a combination of patient health outcomes (such as the number of detected cancers, lives saved or quality adjusted life years (QALYs)), with the resource input (costs for treatment etc.). Health economics not only involves looking at the cost of a healthcare intervention, technology or programme being studied, but also the effectiveness of it. An economic evaluation can be made from different perspectives: that of the health and social care provider (i.e. NHS), the stakeholder, or from a societal perspective, among others. Given the fixed budget the NHS faces, resources should be spent as efficiently as possible.

The more patient safety measures that are used in health and social care, the higher the cost. Therefore, policymakers need guidance on what patient safety interventions to implement to maximise health, care and economic gains. This is not questioning the necessity of patient safety measures themselves, but trying to identify the most efficient use of the existing resources to increase the benefit for patients. Health economics uses different types of evaluations to estimate the effects on the population and the cost to the NHS of the intervention being studied.

Digital technologies are becoming more commonplace within the NHS and in our daily lives, producing rich data on all aspects of our health and care. Connecting the data which is held in, for example, smartphones (such as step counters) and our own Electronic Health Records in primary and secondary care, can help us to gain a deep understanding of patient safety issues and the factors that increase risks of harm.

The Safety Informatics theme will continue its work from the first NIHR Greater Manchester PSTRC, using the wealth of health data which is collected about us, to help prevent harm in our everyday healthcare experiences. One example of the work taking place in Safety Informatics theme is the ACTION intervention, which uses Electronic Health Record data to give feedback to healthcare professionals in Greater Manchester on prescribing safety and management of long term conditions, which creates a ‘learning health system’. The theme will also work on the surveillance of system-wide diagnostic error; patient-led monitoring of test results; and monitoring late effects of cancer treatment.

The PSTRC will build on its existing themes of Safety Informatics and Medication Safety, and their specific focus on digital and diagnostic interventions and polypharmacy. However, the 2017-2022 PSTRC differs from its predecessor in having two new themes:

Safer Care Systems and Transitions

Safety in Marginalised Groups.

Safer Care Systems and Transitions will build on the centre’s previous work on multimorbidity to look at transitions and pathways of care. Transitions can be from one part of the NHS to another (e.g. hospital to primary care), between NHS and private care providers, between the health and social care sectors, or between other sectors and sites including the voluntary sector, self-help groups or “home.” Most research and advances in patient safety are typically found withinsingle discrete care settings, such as the emergency department. Less attention has been paid to safetybetween (transitional) primary, social and community providers and hospital care settings.

The second new theme is Safety in Marginalised Groups. Marginalised Groups include people that are excluded from mainstream social, economic and cultural life. This includes those with mental illness or at risk of suicide or self-harm, people living in nursing homes, the homeless, people with sensory impairment or who speak English as a second language. Such groups are at greater risk of experiencing adverse patient safety outcomes.

In all research themes, service responsibility and patient responsibility for patient safety go hand-in-hand. They are equal – it is a shared responsibility that requires co-design and partnership working, which is why the PSTRC has an involvement and engagement approach supporting all its research.

Self-harm is any act of self-poisoning or self-injury whether intentional or not. Self-harm is the strongest risk factor for possible future suicide, with suicide being the second most common cause of death before the age of 25 worldwide.

In recent years, there has been a rise in suicide rates in children and adolescents, as well as a marked increase in psychological distress. The purpose of this study was to identify how the rates of self-harm have changed, and how these changes compare in different genders, as well as among different age groups. The Clinical Practice Research Datalink (CPRD) database was used to identify 16,912 records of children or adolescents presenting to their GP after self-harming between 2001 and 2014. Researchers then looked at what proportion had been referred to mental health services and what drugs, if any, were prescribed in the 12 months following the self-harm.

The most notable trends were:

A 68% increase in incidence of self-harm in girls aged 13-16

Those who lived in socially deprived areas were 23% less likely to be referred in the 12 months following self-harm

In the second incarnation of the Greater Manchester PSTRC, one of the four themes, and a new theme for the centre, is Safety in Marginalised Groups. This research theme will focus on improving patient safety for marginalised groups of people, who are at a higher risk of harm within the healthcare system. The increased risk can be caused by a number of factors, for example, we know that Black and Minority Ethnic (BME) groups have poorer health outcomes, as well as poorer access to, and experiences of, healthcare services. People may also be marginalised because of stigma and poor access to services for specific conditions (e.g. mental health problems). Or they may be marginalised because of the circumstances or settings in which they live (e.g. living alone, caring for someone at home, living in a rural setting, in a care home or prison, or being homeless).

This theme has two main strands of research: the first on mental health and the second on patients and carers. Over the next five years, the Safety in Marginalised Groups theme researchers will work closely with researchers in other themes to explore a number of key issues, challenges and opportunities for improving safety in marginalised groups including:

communication

self-management: the co-design of tools to aid patients in their healthcare journeys

using mobile technology to monitor health.

A major component of the new theme will be mental health and it is particularly exciting that the PSTRC will be teaming up with the Centre for Mental Health and Safety. Some of the key safety outcomes in mental health involve suicide or self-harm. The proposed programme of work will look at the components of a ‘safe mental health service’ as well as investigating treatment gaps in the care of people who self-harm.

You may not be familiar with the term marginalised groups. So what do we mean by marginalised?

The Oxford English dictionary definition of marginalisation is: “To render or treat as marginal; to remove from the centre or mainstream; to force (an individual, minority group, etc.) to the periphery of a dominant social group; (gen.) to belittle, depreciate, discount, or dismiss.” Within the academic literature, similar definitions have been used. For example, some simply state that marginalised groups are ‘populations outside of “mainstream society”’ (Schiffer K, 2008).

The term is increasingly replacing and/or being associated with other similar terms which you may be more familiar with, such as ‘vulnerable groups’, ‘seldom heard groups’ or ‘hard-to-reach groups’. Although each is different, all these terms include two main aspects. Firstly, there is a main/dominant/central individual or group, (e.g. the government) exerting power over another individual/group, with some sort of disadvantage occurring. In other words, the process of marginalisation leads to unequal outcomes.

Marginalisation is a dynamic process and people can move in and out of such groups. Many people can fall into one or more categories or groups simultaneously, meaning that it is a complex area to research.

In patient safety terms, people belonging to such marginalised groups are likely to experience more and perhaps different patient safety issues in relation to the general population. The truth is we simply don’t know as this is an under-researched area. What we do know however is that there are many barriers to accessing care for those considered to belong to marginalised groups such as migrants, the homeless, and people living in poverty and include issues relating to the way the health and care systems function. We want to understand the range of issues and people we ought to consider in our forthcoming research. This is why we in the Marginalised Groups theme are conducting a review of the published academic literature, identifying and analysing the existing literature on marginalised groups and patient safety in the United Kingdom. This will allow the theme to prioritise its patient safety research agenda over the coming five years.

Blog posts reflect the personal opinion of the author and are not endorsed by the NIHR, the NHS, the Department of Health and Social Care, The University of Manchester, The University of Nottingham or the Greater Manchester Patient Safety Translational Research Centre.